Boon Chin Heng

Philosophy, Ethics, and  Humanities in Medicine

In recent years, clinical assisted  reproduction techniques (ART) are increasingly being practiced worldwide, which  in turn has led to an accumulated surplus of cryopreserved embryos within  fertility clinics [1,2]. Nevertheless, in  those countries where the commercialization of embryo donation is banned – and  former ART patients are expected to donate their cryopreserved supernumerary  embryos altruistically to infertile couples – the resultant effect is often  severe shortages and long waiting lists for prospective recipients [3].  Couples who have attained success in clinical assisted reproduction are usually  reluctant to donate their cryopreserved supernumerary embryos to other couples [4].  This is because frozen embryos are psychologically conceptualized by former  patients as biologic tissue, living entities, 'virtual' children having  interests that must be considered and protected, siblings of their living  children, genetic or psychological 'insurance policies', and symbolic reminders  of their past infertility

 [5]. Under such circumstances,  whereby legally donated embryos are in such short supply and high demand,  medical professionals and health institutions can easily exploit the situation  for profiteering in medical fees, particularly if they possess exclusive rights  of distribution of the donated embryos to prospective recipients.

Although such institutions are not permitted to directly profit from the  transaction of cryopreserved embryos between donor and recipient, it must be  remembered that there is still considerable opportunity for profiteering in  medical fees arising from laboratory and clinical services rendered to the  recipient. It is easy to disguise the 'sale' of altruistically donated human  embryos through substantially increased medical fees, particularly in a private  practice setting. Firstly, patients seeking treatment at privately run IVF

  programs are already prepared to pay higher medical fees for the supposedly  'better' reputation of the fertility doctor and 'enhanced' medical facilities  available. Secondly, it is often the case that patients seeking donated embryos  at a privately-run fertility clinic have already been exasperated by the long  waiting list of government-funded IVF programs, and therefore would have no  qualms with paying higher medical fees. Lastly, a privately run IVF program  would usually treat the medical fees charged to individual patients as  confidential information. Hence, it is difficult for patients to discern whether  there is any disparity in medical fees for a self- and donor-freeze/thaw embryo  transfer cycle, which could, in fact, mask 'opportunistic profiteering' by  medical professionals.
 
 Therefore, the pertinent question that arises is, what would constitute a fair  and honest profit margin for the medical professional and health institution in  question? A suitable benchmark would obviously be the level of medical fees  normally charged to patients for a self-freeze/thaw embryo transfer cycle, after  initial failure at their first attempt in ART. This is because the level of  medical expertise, clinical and laboratory services required for a donor- and  self-freeze/thaw embryo transfer cycle should, in theory, be about the same [6], although slight variation  in treatment can be expected owing to patients' respective medical histories,  which results in varying predisposition to medical complications. In any case,  the health authority should ensure that there is no gross disparity in the  medical fees for both donor- and self-freeze/thaw embryo transfer cycle, as this  could mask opportunistic profiteering by medical professionals and, in fact, be  a covert form of embryo commercialization.

There is nothing deplorable about  profit-making in healthcare services – after all, medical professionals ought to  make a decent living after numerous years of expensive education, coupled with  their heavy investment in medical equipment and facilities. Nevertheless, it is  imperative that they should always work towards a fair and honest profit margin,  rather than exploit the short supply of legally donated human material for  financial gain. It must always be remembered that the embryo donor has  presumably been altruistically, rather than financially, motivated to help the  recipient; such opportunistic profiteering by medical professionals would be an  extreme breach of medical ethics and professional code of conduct, particularly  if they are encouraging their former patients to altruistically donate  supernumerary embryos for the sake of infertile couples. It must be noted that  many childless couples feel a sense of exhilaration and euphoric joy upon  attaining success in clinical assisted reproduction. This altered emotional  state could render them particularly vulnerable to the coaxing of medical  professionals, to whom they feel they owe a debt of gratitude [7].

Another solution for greater transparency  would be to establish a government-controlled national or regional register of  prospective embryo donors and recipients, one successful example being CECOS in  France [8]. This would then facilitate a more equitable  distribution of donated embryos to prospective recipients based on medical condition and needs, rather than choice of medical doctor and health institution  for treatment, the latter providing much room for abuse and opportunistic  profiteering.

1. 	  	Bankowski BJ, Lyerly AD, Faden RR, Wallach EE: The social implications of embryo cryopreservation.Fertility and Sterility 2005, 84:823-832. [

2. 	  	Edwards RG, Beard HK: Destruction of cryopreserved embryos. UK law dictated the destruction of 3000 cryopreserved human embryos.Human Reproduction 1997, 12:3-5. [

3. 	  	Sauer MV, Kavic SM: Oocyte and embryo donation 2006: reviewing two decades of innovation and controversy.Reproductive Biomedicine Online 2006, 12:153-162. [

4. 	  	Klock SC, Sheinin S, Kazer RR: The disposition of unused frozen embryos.New England Journal of Medicine 2001, 345:69-70. [

5. 	  	Nachtigall RD, Becker G, Friese C, Butler A, MacDougall K: Parents' conceptualization of their frozen embryos complicates the disposition decision.Fertility and Sterility 2005, 84:43143-43144. [

6. 	  	Serhal P: Management of the transfer cycle â after freeze/thaw.Fertility and Sterility 1993, 59:936-937.   	  	

7. 	  	Heng BC: Donation of surplus frozen embryos for stem cell research or fertility treatment-should medical professionals and healthcare institutions be allowed to exercise undue influence on the informed decision of their former patients?J Assist Reprod Genet 2006, 23(9â10):381-2. [

8. 	  	Guerin JF: The donation of gametes is possible without paying donors: experience of the French CECOS Federation. Centre for the cryopreservation of eggs and semen.Human Reproduction 1998, 13:1129-1130. [

Philosophy, Ethics, and Humanities in Medicine 2007, 2:3 doi:10.1186/1747-5341-2-3

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In recent years, clinical assisted reproduction techniques (ART) are increasingly being practiced worldwide, which in turn has led to an accumulated surplus of cryopreserved embryos within fertility clinics [1,2].

Author | Boon Chin Heng

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Can the Difference in Medical Fees for Self and Donor Freeze-thaw Embryo Transfer Cycle